Client Intake Form - Hgsitebuilder.com hgsitebuilder

Mark Gelis, MA, LCPC
My Father's House Christian Counseling Services, LLC
(985) 710-1202
Client Intake Form
Client Information:
Today’s Date: ___/___/___ Client’s Name: ___________________________________
Phone Numbers: (Home) ________________ (Work) __________________ (Cell) _________________
Can we call you at work Yes / No
Address: _______________________________________________________________
City: ______________________________ State: ___________ Zip ____________
Age: ____ Birth Date: ___/___/___
Marital Status:[ ] Single [ ] Engaged
[ ] Married – How Long _____ - How many times _____
[ ] Separated – How Long [ ] Divorced – How long _____
Education: ______________________________ Occupation: ___________________
Place of Employment: _____________________________________________________
♦♦♦
Counseling History:
Briefly describe the reason(s) you are seeking counseling: _________________________
________________________________________________________________________
What is your most difficult relationship right now ______________________________
What is your most difficult emotion right now _________________________________
Who is coming for counseling ______________________________________________
Have you had any previous counseling ____ If yes, when ________
Where / With Whom __________________ Why __________________
Are you, or a family member, currently seeing a psychiatrist or another counselor _____
If so, what family member _____________ Psychiatrist / Counselor Name: __________
For what reason ________________________________________________________
♦♦♦
Crisis Information:
Are you currently having suicidal thoughts, feelings, or actions Yes / No
If yes, explain: _____________________________________________
Are you currently homicidal / assaultive thoughts or feelings, or anger-control problems Yes / No If yes,
explain: _____________________________________________
Have you had any past problems, hospitalizations, incarcerations for suicidal or assaultive behavior Yes /
No If yes, explain: ___________________________________
Are you currently experiencing any current threats of significant loss or harm (illness, divorce, custody,
job loss, etc.) Yes / No
If yes, describe: __________________________________________________________
Emergency Contact Information (name, relationship, phone number, address):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Client’s Name: __________________________________________________________
Medical Information:
When were you last examined by a physician ____________
Name of physician: _____________________________ Phone: _________________
Address: ________________________________________________________________
List any medical conditions you are currently being treated for: ____________________
_______________________________________________________________________
List any medications you are currently taking:
Name of Medication Frequency Taken Reason for Medication
_______________________ / ________________________ / ___________________________
_______________________ / ________________________ / ___________________________
_______________________ / ________________________ / ___________________________
_______________________ / ________________________ / ___________________________
If you enter into therapy with me, may I tell your medical doctor so that he / she can be fully informed
and we can coordinate your treatment Yes / No
♦♦♦
Complete this section if client is under the age of 18.
Parent / Guardian’s Name: _____________________________________
Phone Numbers: (Home) ____________ (Work)_______________ (Cell)_____________ (Beeper)
______________
Can we call you at work Yes / No
Age: ____ Birth Date: ___/___/___ Marital Status:[ ] Single [ ] Engaged
Education: ________________________ Place of Employment: _________________
♦♦♦
Spouse’s Name: ___________________________________________
Phone Numbers: (Home)____________ (Work)_______________ (Cell)______________ Can we call
him / her at work Yes / No
Address: ________________________________________________________________
Age: ____ Birth Date: ___/___/___
Marital Status:[ ] Single [ ] Engaged
[ ]Married – How Long _____ - How many times _____
[ ] Separated – How Long _____ [ ] Divorced – How long _____
Education: _________________________________________________
Occupation: ________________________________________________
Place of Employment: _________________________________________
♦♦♦
Client’s Children:
List name, birth date, sex, relationship of all children, and whether they live at home with you.
Name Birth Date Sex Relationship At Home
_____________________ / ______________ / __________ / ________________ / _______________
_____________________ / ______________ / __________ / ________________ / _______________
_____________________ / ______________ / __________ / ________________ / _______________
_____________________ / ______________ / __________ / ________________ / _______________
_____________________ / ______________ / __________ / ________________ / _______________
_____________________ / ______________ / __________ / ________________ / _______________
2

Client’s Name: __________________________________________________________
♦♦♦
Client’s Family of Origin:
Father: First Name ____________ Age ____ Occupation ______________
State of Health _____________________ Resides in _______________
If deceased, how and when _____________________________________
List 3 words that best describes him (ex: loving, mean, etc.) ___________
____________________________________________________________
How do / did you get along with him _____________________________
Mother: First Name ____________ Age ____ Occupation ______________
State of Health _____________________ Resides in _______________
If deceased, how and when _____________________________________
List 3 words that best describes her (ex: loving, mean, etc.) ___________
____________________________________________________________
How do / did you get along with her _____________________________
Stepfather: First Name ____________ Age ____ Occupation ______________
State of Health _____________________ Resides in _______________
If deceased, how and when _____________________________________
List 3 words that best describes him (ex: loving, mean, etc.) ___________
____________________________________________________________
How do / did you get along with him _____________________________
Stepmother: First Name ____________ Age ____ Occupation ______________
State of Health _____________________ Resides in _______________
If deceased, how and when _____________________________________
List 3 words that best describes her (ex: loving, mean, etc.) ___________
____________________________________________________________
How do / did you get along with her _____________________________
♦♦♦
Brothers and Sisters: Please list in birth order.
Name Age Sex Where Reside Relationship With Client
(close / distant / in between)
_____________________ / ________ / _______ / ________________ / ________________________
_____________________ / ________ / _______ / ________________ / ________________________
_____________________ / ________ / _______ / ________________ / ________________________
_____________________ / ________ / _______ / ________________ / ________________________
_____________________ / ________ / _______ / ________________ / ________________________
_____________________ / ________ / _______ / ________________ / ________________________
♦♦♦
Have you ever experienced any of the following:
[ ] Harsh physical punishment or abuse as a child
[ ] Sexual advances made toward you as a child
[ ] Sexual abuse
[ ] Incest
[ ] Rape
[ ] Physical abuse by spouse or lover
[ ] Verbal or emotional abuse as a child or adult
If so, please explain:
3

Substance Use/Abuse History (N/A is not applicable)
Substance First Use Last Use Current Use
Depressants
Alcohol _____________ ______________ ______________
Inhalants _____________ ______________ ______________
Barbiturates _____________ ______________ ______________
Hallucinogens _____________ ______________ ______________
Marijuana _____________ ______________ ______________
LSD _____________ ______________ ______________
Mushrooms _____________ ______________ ______________
PCP _____________ ______________ ______________
Stimulants _____________ ______________ ______________
Amphetamines _____________ ______________ ______________
Cocaine _____________ ______________ ______________
Crack(freebase)_____________ ______________ ______________
Other _____________ ______________ ______________
♦♦♦
Client’s Religion / Faith:
Religious Affiliation during childhood: ________________________________________
Religious Affiliation now: __________________________________________________
Level of meaningfulness of religious affiliation during childhood and adolescence:
High Medium Low
Level of meaningfulness or religious affiliation now:
High Medium Low
Attached is a Client Information Form which outlines the counseling policies and related information
with a consent to treatment. Please read these forms, discuss any concerns, sign, and return them to me. If
you have any questions regardinging fees or other issues, please ask.
♦♦♦
This is a strictly confidential client record.
Client’s Signature: ____________________________ Date __/___/___
____________________________ Date __/___/___
Referral Information: Who referred you to me for counseling
Name: __________________________ Phone: __________________
May I have your permission to thank this person for the referral Yes / No
4